GW1-2022-08703_Well Construction - GW1_20220530

WELL CONSTRUCTION RECORD(GW-1) For Internal Use Only:
1.Well Contractor Information:
DAVID HALL �14;WATEA'ZONES
Well Contractor Name FROM TO DESCRIPTION
ft. ft
r-
A - 4459 ft. f'.
NC Well Contractor Certification Number FiCEP 1E
i 15.OUTEWCASING(6r TWti-casad`welh)',,0�=rip licable)
GEOLOGIC EXPLORATION FROM TO DIAMETER in. MATERIAL ft.
Company Name " ur;n
q_-'J 1: 16.INNER CASING,OR TUBING(F'ebtliernial closed-loop)"
2.Well Construction Permit#: J,,f'^ffV1r1a' 0;1,,C�G FROM TO DIAMETER THICKNESS MATERIAL
List all applicable well construction permits(i.e.UIC,County,State,Variance,etc.) 0.0 It. 10.0 It. 2.0 in. SCH 40 PVC
3.Well Use(check well use): ft. ft. in.
��,""­�­e"
Water Supply Well: A7.SCREEN
FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
ElAgricultural DMunicipal/Public 10.0 ff 25.0 It' 2.0 "' .010 SCH 40 PVC
ElGeothermal(Heating/Cooling Supply) oResidential Water Supply(single) I, ft. in.
Olindustrial/Commercial oResidential Water Supply(shared) '18.GROUT;
DIrrigation DWells>100,000 GPD FROM TO MATERIAL EMPLACEMENT METHOD&AMOUNT
Non-Water Supply Well: 0.0 5.0 PORTLAND BENTONITE SLURRY
INMonitoring DRecovery ft. ft.
Injection Well: ft. ft.
0 Aquifer Recharge 0 Groundwater Remediation 19.SANDIGRAVEL PAC 01'applica,ble)
LlAquifer Storage and Recovery oSalinity Barrier FROM TO MATERIAL EMPLACENIENTMEMOD
oAquiferTest 0 Stormwater Drainage 8.0 ft- 25.0 ft. 20-40 FINE SILICA SAND
ElExperimental Technology 0 Subsidence Control ft. ft.
DGeothermal(Closed Loop) OTracer 20.DRILLINGLOG(attach additional sheets'ifnecessary)i
DGeothermal(Heating/Cooling Return) 0 Other(explain under#21 Remarks) FROM I TO DESCRIPTION(color,hardness,soil/rock type,grain sin,etc.)
0.0 fl. 5.0 f- RED CLAY
4.Date Well(s)Completed: 04/05/22 Well TD# MW-2 5.0 It- 25.0 ft- TAN SILTY SAND
5a.Well Location: ft. ft.
CHARLIE BROWN DRYCLEANER ft. ft.
Facility/Owner Name Facility ID#(if applicable) ft. ft.
3701 FREEDOM DRIVE CHARLOTTE 28208 ft. ft.
Physical Address,City,and Zip ft. ft.
MECKLENBURG
County Parcel Identification No.(PIN) BENTONITE SEAL-5.0-8.0 FEET
5b.Latitude and longitude in degrees/minutes/seconds or decimal degrees:
(ifwcll field,one hit/long is sufficient) 22.Certification:
350 14' 55.18" N 800 53' 52.11 W a� 25/22
6.Is(are)the well(s): 119Permanent or OTemporary Signature of Certified Well Contractor Date
By signing thisform,I hereby certify that the ipell(s)ipas(were)constructed in accordance ivith
7.Is this a repair to an existing well: DYes or 15No 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a copy
If this is a repair,fill out known well construction information and explain the nature ofthe ofthis record has been provided to the well owner.
repair under#21 remarks section or on the back ofthis form. 23.Site diagram or additional well details:
8.For Geoprobe/DPT or Closed-Loop Geothermal Wells having the same You may use the back of this page to provide additional well construction info
construction,only 1 GW-I is needed. Indicate TOTAL NUMBER of wells (add'See Ovee in Remarks Box).You may also attach additional pages if necessary.
drilled: 24.SUBMITTAL INSTRUCTIONS
9.Total well depth below land surface: 25.0 (ft.) Submit this GW-1 within 30 days of well completion per the following:
For multiple wells list all depths ifelifferent(example-3@200'and 2@100)
10.Static water level below top of casing: 10.0 24a. For All Wells: Original form to Division of Water Resources (DWR),
Ifivater level is above casing,use"+" (ft*) Information Processing Unit,1617 MSC,Raleigh,NC 27699-1617
11.Borehole diameter: 8.0 (in.) 24b.For luiection Wells: Copy to DWR,Underground Injection Control(TUC)
Program,1636 MSC,Raleigh,NC 27699-1636
12.Well construction method: AUGER
24c.For Water Supply and Open-Loop Geothermal Return Wells:Copy to the
(i.e.auger,rotary,cable,direct push,etc.) county environmental health department of the county where installed
FOR WATER SUPPLY WELLS ONLY: 24d.For Water Wells producing over 100,000 GPD:Copy to DWR,CCPCUA
13a.Yield(gpm) Method of test: Permit Program,1611 MSC,Raleigh,NC 27699-1611
13b.Disinfection type: Amount:
Form GW-1 North Carolina Department of Environmental Quality-Division of Water Resources Revised 6-6-2018